Eggiman v. Self-Insured Services Co.

718 N.W.2d 754, 39 Employee Benefits Cas. (BNA) 1794, 2006 Iowa Sup. LEXIS 94, 2006 WL 2089236
CourtSupreme Court of Iowa
DecidedJuly 28, 2006
Docket05-0246
StatusPublished
Cited by7 cases

This text of 718 N.W.2d 754 (Eggiman v. Self-Insured Services Co.) is published on Counsel Stack Legal Research, covering Supreme Court of Iowa primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Eggiman v. Self-Insured Services Co., 718 N.W.2d 754, 39 Employee Benefits Cas. (BNA) 1794, 2006 Iowa Sup. LEXIS 94, 2006 WL 2089236 (iowa 2006).

Opinion

STREIT, Justice.

A woman suffering from clinical obesity alleges the company processing claims on behalf of her health insurance plan made misrepresentations that led her to obtain treatment not covered by the plan. Mary Eggiman filed the present action against her husband’s employer, R.H. Hummer, Jr., Inc., and Self-Insured Services Company (SISCO), the claims processor for the health insurance plan. Hummer and SIS-CO filed a motion for summary judgment. This motion argued the denial of benefits was proper because Eggiman failed to obtain pre-authorization for the surgery. The motion also argued the misrepresentation claim against SISCO was improper because SISCO was not a fiduciary under the Employee Retirement Income Security Act (ERISA). 29 U.S.C. §§ 1001, et seq. (2000). The district court found as a matter of law it was proper to deny benefits based on Eggiman’s failure to obtain pre-authorization. The court also concluded SISCO was not an ERISA fiduciary and therefore could not be found liable for any allegedly misleading statements made to Eggiman. The court of appeals affirmed the district court ruling. On further review, we vacate the decision of the court of appeals and reverse the portion of the district court order which found SISCO was not an ERISA fiduciary and therefore could not be liable for any misleading statements made to Eggiman.

I. Background Facts and Proceedings

Eggiman suffers from clinical obesity. In 2001, her physician recommended she consider gastric bypass surgery. Eggi-man is insured through her husband’s employer, R.H. Hummer, Jr., Inc., a trucking firm. Hummer utilized a self-insured health and medical plan (hereinafter “Hummer Health Plan”) as a benefit for its employees. The Hummer Health Plan is governed by a “plan document” detailing the benefits, rights, and privileges of covered individuals. In essence, the plan document explains when the plan will pay or reimburse all or a portion of covered expenses. SISCO marketed and sold this plan to Hummer. SISCO is also the “claims processor” for the plan. Through a service agreement between SISCO and Hummer, SISCO contractually agreed to perform various functions related to the administration of the plan. Healthcorp, Inc., SISCO’s sister company underneath the same corporate umbrella, is listed in *756 the plan document as the “review organization.”

The Hummer Health Plan provides the following conditions for the coverage of a gastric bypass procedure:

26. Charges for services in connection with surgical treatment of morbid obesity will be considered Eligible Expenses, subject to the following conditions:
a. A second concurring opinion is required prior to the surgical procedure; and
b. Pre-authorization is required. Coverage is subject to the following guidelines:
a. Body weight must be at least 200% of the optimal weight.
b. The covered individual must have been considered morbidly obese by a Physician for at least five (5) years prior to the date surgical treatment is sought.
c. Non-surgical methods of weight reduction must have been attempted under a Physician’s supervision for at least a three (3) year period immediately prior to the date surgical treatment is sought.

On April 23, 2001, a health insurance review specialist hired by Eggiman’s physician sent a letter to SISCO requesting a review and authorization for the gastric bypass surgery. Among other things, the physician’s health insurance review specialist informed SISCO that Eggiman weighed 283.8 pounds and was 132.8 pounds overweight.

On May 14, 2001, the physician’s health insurance review specialist received a letter from Cottingham & Butler (hereinafter “C & B”) 1 denying “eligibility” because the following criteria had not been met:

(1) Eggiman’s weight was less than 200% of her optimal weight, (2) there was no documentation from a physician indicating she had been morbidly obese for at least five years, (3) there was no documentation of at least three years of unsuccessful physician supervised weight-loss plans, and (4) there was no second surgical opinion.

On June 5, 2001, Eggiman received a letter from C & B, signed HealthCorp, Inc., informing her that “hospitalization cannot be certified due to” insufficient information. Eggiman called SISCO and spoke with a representative about what information was still needed for certification.

On June 15, 2001, the physician’s health insurance review specialist received another letter from C & B. This letter stated the following criteria had been met: (1) Eggi-man was considered morbidly obese by a physician for at least the previous five years, and (2) non-surgical methods of weight reduction had been attempted under a physician’s supervision for at least a three year period prior to the date of the proposed surgery. However, the letter denied “eligibility” because a second surgical opinion had not- been obtained and Eggiman’s weight was only 188% of her ideal weight. There is no indication this letter was sent to Eggiman.

On the same day, Eggiman received a letter from C & B, signed HealthCorp. Inc., that stated:

[Mary Eggiman] has been pre-certi-fied for a GASTRIC BYPASS FOR OBESITY by HealthCorp, the managed care company selected by your employer. At this time a date has not been established for the procedure. Health- *757 Corp should be notified ... when a date is confirmed.
The physician, SISCO, and the hospital have been notified of your certification. IT DOES NOT GUARANTEE PAYMENT.
Healthcorp’s certification process evaluates the appropriate length of hospital stay and/or the appropriateness of services provided. Please be advised that the determination of your benefits will be decided by the rules within your company’s health plan document. Any reimbursement is based on the services that were provided, the participant’s eligibility and the plan limitations.

(Emphasis in original.)

On July 24, 2001, Eggiman received another letter from C & B, signed by Health-Corp. Inc. The letter stated the following:

This letter is to notify you that your upcoming hospitalization, listed above, has been precertified. The length of stay precertified is an anticipated length of stay. If additional days are medically appropriate, the length of stay will be increased.
You will receive a “final certification” letter after your discharge from the hospital. The final letter will include all days certified for this hospitalization.
Healthcorp’s certification process determines the medical appropriateness of hospitalization and/or services provided. The final determination of continued hospitalization is the decision of the attending physician. The final determination of benefits will be made by SIS-CO.

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718 N.W.2d 754, 39 Employee Benefits Cas. (BNA) 1794, 2006 Iowa Sup. LEXIS 94, 2006 WL 2089236, Counsel Stack Legal Research, https://law.counselstack.com/opinion/eggiman-v-self-insured-services-co-iowa-2006.